Sexual Health Issues and Sources of Information on HIV for High-Risk Groups In February 2013 the Leaders’ Committee at London Councils recognised the shortcomings of the Pan London HIV Prevention Programme (PLHPP) approach to HIV prevention. In response, the Association of Directors of Public Health (ADPH) London, working with London Councils, designed the Future Commissioning of London HIV Prevention Services (FCLHPS) Project to oversee a London-wide needs assessment over the summer of 2013. The FCLHPS project included six work streams:

- Epidemiological review
- Evidence review update
- A Call for Evidence
- Stakeholder engagement
- Segmented insight research
- Mapping of current HIV prevention.

The overall findings of the needs assessment are published in the report: “HIV Prevention Needs Assessment for London” (November 2013). This report is the output of one of the six underpinning work streams, and focused on the segmented insight research. ADPH London and London Councils will develop an options paper for a meeting of the leaders of the 33 councils in London, due to take place in November 2013. Sexual health issues and sources of information on HIV for high-risk groups

Key findings from focus groups held with gay men and black Africans

Authors: Heather Barker, Helena Ball and John Isitt

October 2013 Contents

1 Summary of key findings ................................................................. 4 2 Context .......................................................................................... 5 3 Methodology .................................................................................. 6 3.1 Recruitment .............................................................................. 6 3.2 Focus groups ............................................................................ 7 4 Findings: Gay men ......................................................................... 8 4.1 Focus group participants .......................................................... 8 4.2 Key findings ............................................................................. 8 4.2.1 Accessing information ......................................................... 8 4.2.2 Health priorities ................................................................. 8 4.2.3 Awareness / knowledge about HIV and other STIs ............... 8 4.2.4 The extent to which HIV is an issue for individuals ............. 9 4.2.5 Sources of information, advice and support on sexual health / HIV 9 4.2.6 The health / HIV services used by individuals .................... 9 4.2.7 What key messages should be delivered? ............................ 9 4.2.8 Channels of communications ............................................. 10 4.2.9 Who / what are credible sources of information? ................. 10 4.2.10 How important is confidentiality, convenience and credibility? 10 4.3 Detailed findings ..................................................................... 11 4.3.1 Use of media to access information .................................... 11 4.3.2 Attitudes to overall health .................................................. 11 4.3.3 Knowledge of and attitudes to HIV and AIDS .................... 12 4.3.4 How can the spread of HIV be prevented? ......................... 13 4.3.5 Searching for information relating to sexual health and HIV .... 14 4.3.6 Delivering specific messages in relation to HIV and HIV prevention 15 4.3.7 Comments on previous campaigns and materials ............... 18 5 Findings: Black African ................................................................. 19 5.1 Focus group participants .......................................................... 19 5.2 Key findings ............................................................................. 21 5.2.1 Accessing information ......................................................... 21 5.2.2 Health priorities ................................................................. 21 5.2.3 Awareness / knowledge about HIV and other STIs ............... 21 5.2.4 The extent to which HIV is an issue for individuals ............. 22 5.2.5 Sources of information, advice and support on sexual health / HIV 22 5.2.6 The health / HIV services used by individuals .................... 22 5.2.7 What key messages should be delivered? ............................ 22 5.2.8 Channels of communications ............................................. 23 5.2.9 Who / what are credible sources of information? ................. 23 5.2.10 How important is confidentiality, convenience and credibility? 24 5.3 Detailed findings ..................................................................... 25 5.3.1 Use of different media to access information ....................... 25 5.3.2 Attitudes to overall health .................................................. 25 5.3.3 Knowledge of and attitudes to HIV and AIDS .................... 26 5.3.4 Searching for information relating to sexual health and HIV .... 29 5.3.5 Delivering specific messages in relation to HIV and HIV prevention 32 5.3.6 Comments on previous campaigns and materials ............... 35 6 Discussion ........................................................................................................... 35 7 Appendices ........................................................................................................... 38 7.1 Appendix 1 – Recruitment screening tools .................................................. 38 7.1.1 Recruitment screening questionnaire – West African women ............... 38 7.1.2 Recruitment screening questionnaire – gay men .................................. 40 7.2 Appendix 2 – Discussion guide for gay men .............................................. 44 7.3 Appendix 3 – Discussion guide for black African groups ......................... 49 7.4 Appendix 3 – Logo images used in focus groups ...................................... 54 1 Summary of key findings

Six focus groups were held in September 2013 to explore the perceptions of high-risk groups (gay men and black Africans) to sexual health services and HIV prevention information in London.

There was a high level of commonality in the perspectives of the black African groups and the group of gay men although there were some variations and differences. The key findings are summarised below, and where there were differences between groups, these have been highlighted.

Knowledge of sexual health and HIV

- All of the groups believe that health is a priority
- Gay men are more aware of their sexual health and have a higher level of awareness and understanding of HIV
- While HIV is an issue for all, it seemed to be more of an issue for gay men who “live” with the danger of contracting the virus. Gay men recognised that they are at high risk but highlighted that other groups are also at risk. In the black African groups those born outside the UK had a high awareness of HIV but those who were UK born did not have confidence in the statistics and felt that they are not a special group - everyone is at risk.

Accessing media and information

- All groups search for information on the Internet – and sexual health clinics provide information and support to all groups
- All groups access mainstream media and read the free London papers Metro and Evening Standard. Some of the gay men also access gay community media to gain the ‘gay perspective’. The black African groups did not know of or use UK-based ‘black’ media, they do however access publications about their home countries.

Sources / organisations for HIV information

- All felt that it is important that any messages should come from a credible and respected source. The NHS is seen by all to be the most credible source of information and felt that messages should be seen to come from either the NHS or Department of Health. Local authorities were not seen as credible in this area – they are more associated with bins and Council Tax
- Gay men were more likely to know about specialist groups (such as Terence Higgins Trust and National AIDS Trust) while black African groups were less aware of specialist support and were concerned about accessing support from community groups because of confidentiality issues.

Messages and channels for HIV information

- All groups agreed that the key message that needs to be “out there” is that HIV can affect anyone and everyone. HIV does not discriminate nor should awareness programmes be seen to
- All groups talked of the need to avoid discrimination in advertising and awareness raising materials and were concerned that “tailored” literature would only serve to promote the concept that HIV is a “gay” or a “black” disease alienating them further from the wider community • All groups agreed that the channels of communication should allow individuals to read and absorb the message at a time and place that suits them – and that these messages should reach the whole population. There was also agreement on the fact that there is a need for much better education in schools. • Confidentiality is something that is important to everyone – and is more important than convenience, since many are prepared to go outside their area for services like HIV testing to ensure confidentiality.

2 Context

In February 2013 the Leaders Committee at London Councils recognised the shortcomings of the Pan London HIV Prevention Programme (PLHPP) approach to HIV prevention. In response, Association of Directors of Public Health (ADPH) London, working with London Councils, designed the Future Commissioning of London HIV Prevention Services (FCLHPS) Project to oversee a London-wide needs assessment over the summer of 2013.

The FCLHPS project included six work streams: • Epidemiological review • Evidence review update • A Call for Evidence • Stakeholder engagement • Segmented insight research • Mapping of current HIV prevention

The overall findings of the needs assessment are published in the report, "HIV Prevention Needs Assessment for London" (November 2013). This report is the output of one of the six underpinning work streams and is focused on the segmented insight research. ADPH London and London Councils will develop an options paper for a meeting of the leaders of the 33 councils in London, due to take place in November 2013.

The segmented research part of this needs assessment was conducted to gather feedback and insights from the groups most at risk of HIV infection in London. In particular, this element of the needs assessment sought to understand the perspective of these at risk groups on HIV prevention approaches. While the research was intended to elicit insights and views in relation to the particular areas outlined in the methods section, the broader aim was to provide a richer understanding of the context in which current and future HIV prevention interventions and services are/will be delivered.

This report outlines the findings from the segmented insight research. 3 Methodology

In order to determine the public perspective on sexual health and HIV prevention issues a series of focus groups were convened with 62 individuals from the gay men and black African communities in London. Six different focus groups were held:

- Gay men
- West African women
- West African men
- South African women
- South African men
- East African men.

3.1 Recruitment

The groups were recruited on the street using screening questionnaires (see Appendix 1 for examples). These screening tools ensured that those recruited were sexually active, had a range of ages and lived in a variety of London boroughs. Anyone who worked for or volunteered for a sexual health charity or community group was excluded, as were those who had taken part in a discussion group in the last 12 months.

The screening tool also ensured that those recruited for the black African groups had a family background from the relevant countries and that approximately half were born in Africa and half in the UK (with at least one of their parents born in Africa). Those recruited for the gay men focus group self-identified as bisexual or homosexual and there were a range of drug taking behaviours represented.

To try to ensure the intended focus group size was 8 – 10 participants, 10 – 12 people were recruited for each to group to allow for non-attendance. In total 68 people were recruited and 62 participated in the focus groups. Those recruited were told that they should not bring friends to the group, but some individuals still arrived at the groups with additional people. If the additional people matched the focus group profile they were still included in the focus group to maintain good relations with all participants.

| Session | Respondents recruited | Participants | Location | |-----------------------|-----------------------|--------------|------------| | Gay men | 12 | 13 | Westminster| | West African women | 12 | 14 | Southwark | | West African men | 12 | 9 | Southwark | | South African women | 10 | 6 | Brent | | South African men | 10 | 8 | Brent | | East African men | 12 | 12 | Brent | 3.2 Focus groups

The focus groups were conducted between 9 and 16 September 2013 on week day evenings in community venues. The venues were in boroughs where the 2011 census indicated high numbers of the target audience live and within easy reach of public transport. Participants received a £40 incentive for their time.

Each focus group was 90 minutes long and based on prepared discussion guides (see Appendices 2 & 3). The groups were designed to be “non-threatening” and confidential and to engage participants in thinking about their health as well as sharing their knowledge and awareness of HIV and its impact on individual lives. They included:

- Ways in which individuals access general information, thinking specifically about where they get information and the key channels / means of communication
- Individuals' health priorities
- Levels of awareness and knowledge about HIV
- Perceived risk and the general ‘relevance’ of HIV
- How do individuals access information about sexual health and HIV?
- What are the key messages?
- What are the appropriate channels of communication and what sources of information are trusted and credible?
- Should prevention programmes be delivered at national, regional or local (community) level?
- Thoughts on previous awareness campaigns and related materials.

To support testing who and what channels provide trusted and credible information, the facilitator showed participants logos and names of various organisations (including the NHS, councils, community organisations and well-known retail brands – see Appendix 4). Previous campaign materials for the relevant target groups were also shared with participants to understand their reaction to the messages included and how they were conveyed. These campaign materials were supplied by organisations including the Terence Higgins Trust, GMFA and Embrace UK.

The discussions were recorded and written notes were also taken during the sessions. This ensured that any “gaps” or confusion arising from the recording could be rectified.

The data was analysed by three researchers using a grid analysis in which responses from each of the groups were grouped under the main headings outlined above. This enabled easy identification of common themes and any differences between the groups.

Insights gathered from the focus groups are presented separately for gay men and black Africans. For each broad group findings are firstly presented in a summary format followed by a more detailed explanation of the findings. 4 Findings: Gay men

4.1 Focus group participants

| Gay men focus group – 9 participants | |-------------------------------------| | Age | | Range: 25 – 44 | | 2 20s, 4 30s, 3 40s | | Ethnicity | | 3 BME, 5 White British, 1 White Other | | Boroughs | | 7 Inner-London: 2 Lambeth, 2 Islington, 2 Wandsworth, 1 Haringey | | 2 Outer-London: Enfield and Bromley | | Drug use | | 4 recreational drugs, 2 injected drugs, 3 no drug use |

4.2 Key findings

4.2.1 Accessing information

- Individuals use a wide range of broadcast, print and online media to access general information. This includes free media (Metro and Evening Standard) and paid media (daily newspapers) as well as online information available through free apps.
- About half of the group also read specialist, gay, media to gain a gay perspective and commentary on events.

4.2.2 Health priorities

- The key health priorities are healthy living and fitness
- Priorities are influenced by aging and “wake up calls” that are usually the result of personal illness or illness of friends and family
- Sexual health is a priority and the majority of individuals attend the Sexual Health Clinic on a regular basis.

4.2.3 Awareness / knowledge about HIV and other STIs

- There are high levels of awareness and knowledge of HIV and STIs among the age groups of the individuals that attended the focus group
- It is recognised that HIV is a sexually transmitted disease and also that it can be transmitted by blood transfusions and by shared needles
- Individuals are aware that there are four keys ways in which they can protect themselves; abstinence, use of condoms, practising safer sex and ensuring that any potential partners have been tested before entering into a sexual relationship • There is concern that the same levels of awareness and knowledge are not held within younger age groups as the levels of advertising and education that were in place at the end of the 20th century no longer exist • There is a perceived need to raise awareness not only among young people but also the wider heterosexual population.

4.2.4 The extent to which HIV is an issue for individuals • HIV is an issue that is talked about within the gay community and individuals “live” with the danger of contracting the virus • This danger and knowledge leads the majority to practice safer sex and to be tested on a regular basis.

4.2.5 Sources of information, advice and support on sexual health / HIV • The key sources of information on sexual health and HIV are the internet and Sexual Health Clinics. In terms of the internet, Google is the preferred search engine and the results and information obtained are generally found to be helpful and credible • Some information is also obtained from leaflets and posters that are displayed in clubs and public toilets.

4.2.6 The health / HIV services used by individuals • The key services used are Sexual Health Clinics - either those that are on a permanent site or the mobile clinics that, from time to time, are located in clubs • There is a lack of trust in sexual health services provided by GPs as it is felt that GPs lack specialist knowledge of HIV (they are general practitioners) and there are concerns over their lack of confidentiality, especially with insurance companies.

4.2.7 What key messages should be delivered? • It was agreed that the most important message to be delivered is that HIV can affect anyone. Further, everyone needs to understand the implications of getting HIV and how to prevent it • Participants felt that the message should be designed to shock and make people stop, think and take action • They also believed that it is important for the message to reach beyond the “established” gay community into the wider community and to o Individuals who may be gay but who do not visit gay venues and / or are not part of the gay scene o The wider population and especially heterosexual males aged 30+ who are seen to indulge in very risky sexual behaviour with no awareness of the risk and potential to contact HIV • Given their desire to extend awareness into the wider community, participants agreed that it is not appropriate to use awareness raising materials that focus specifically on the gay community and that are sexually very explicit. They believed that this o “Fuels” the idea that HIV is a gay disease and could further stigmatise the gay community Alienates sectors of the community (including the gay community) who would see the images / words as obscene and not take notice.

4.2.8 Channels of communications

- All of the participants agreed that messages should be delivered through a coordinated campaign that has both a national and local focus. The channels of communication used should allow individuals to read and absorb the message at a time and place that suits their needs; messages should not be forced on individuals through phone calls, text messages, emails or letters.
- They also believe it is important that whatever channels are used, they are accessible to everyone and not just the gay community. These could include:
  - Metro / Evening Standard
  - Bus back
  - You Tube
  - Pops ups on line
  - TV advertising

4.2.9 Who / what are credible sources of information?

- The entire group felt that any messages should be seen to come from a credible and trusted source. This includes:
  - NHS organisations – with the importance of the logo being stressed
  - Department of Health
  - Terence Higgins Trust (THT) / National Aids Trust (NAT)
- They do not consider Local Authorities to be credible as they are too closely associated with provision of Council Services and the extent to which they can be specialists and knowledgeable about HIV is questionable.

4.2.10 How important is confidentiality, convenience and credibility?

- Individuals noted that confidentiality and credibility are the most important factors in accessing information and support relating to HIV.
- Individual participants talked of going to STI clinics and other health services outside their local area in order to maintain confidentiality despite any inconvenience this may cause. 4.3 Detailed findings

4.3.1 Use of media to access information Respondents talked of accessing information via a range of different media according to the nature of the information / support required. This includes broadcast media, print and on-line information services. A number also talked of going on line to the BBC news website to keep up to date with current affairs and information during the day. At the same time, everyone who travels by public transport picks up copies of the Metro and Evening Standard on a daily basis.

“I listen to the BBC news at home and then read Metro” “Listen to BBC news and then use the BBC website” “I use the BBC website to keep up to date during the day” “I read all of the free newspaper apps.”

About half of the group talked of accessing media that is specific to the gay community. This includes news-based media such as the Pink News and the gay and lesbian section of the Huffington Post. The key reasons for accessing specific media are to find out what is happening within the community and to look at news from the point of view of the gay community.

“Buying gay press – people talk in a straight way about things that you don’t get in the ordinary press” “It (Gay Times) is quite sarcastic some days and light hearted. Gives a different point of view” “I read the Huffington post on line because they have a gay and lesbian section. It is recent and it is on line” “I go on the website for Pink News – good because it helps you know what is going on in the gay world politically.”

Individuals also read other, magazine style, publications such as Boyz, Attitude and the free papers that are available in gay clubs.

“I haven’t actually bought any gay magazine, I have just seen Boyz in a club” “I always pick up the free papers in a club.”

4.3.2 Attitudes to overall health Overall, health and well-being is considered to be very important and individuals take action to ensure that they are fit and healthy.

“I go to the gym and use the internet to motivate me – there is lots of motivation on You Tube on eating the right things, changing diet, exercise.”

There are a number of factors that influence the extent to which health is a priority and will encourage individuals to take action. These include:

- Getting older “You tend to be more careful the older you get – reduce the amount I drink and try to eat the right things”

- A personal “wake up call” through a personal illness or illness of a friend / family member “But the only way I would do something …. is if my health was affected or someone close to me was affected” “I ran for the train and realised that a week of overeating and indulgence was just not good for me!”

- Concern about sexual health “You care your health but do you care for your sexual health? Because sometimes you get really drunk and do things you shouldn’t do. It makes you take action.”

- However, some individuals also felt that although their health is important, they don’t always take the action they know they should take to keep themselves healthy and fit. “It is a bit of a paradox – think so much about it but don’t do anything about it. Am I as healthy and fit as I could be; would I like to my body to be another way.”

4.3.3 Knowledge of and attitudes to HIV and AIDS

Overall awareness, perceptions of HIV and how it is transmitted

a) Levels of awareness There was widespread knowledge of HIV and AIDS, which is attributed to the fact that HIV affected many in the gay community, either directly or through friends and acquaintances. “The gay world knows all about it because it is something you are brought up with.”

However there is also a perception that the high levels of awareness among the gay community are declining. Awareness was highest amongst the older participants but those in their 20s were also highly aware. Those in the group were worried about awareness amongst younger gay men (teens). “In the 1980’s it used to be promoted and everyone knew about it. Now there is nothing and no-one knows.”

b) What is HIV, how is it transmitted and how serious is it? HIV is known to be a sexually transmitted disease that can affect anyone and everyone. It is seen to be a serious condition that can ultimately be life threatening. “It is a sexually transmitted disease. Used to be limited to gays but no longer” “Some people will die from HIV and AIDS...It is that serious” “It was seen as a gay disease and then you discovered that children were born with the disease. And I didn’t understand it why was it that unprotected sex caused it? When children had it too?”

However, it was noted that treatments have improved over the years to the extent that HIV / AIDS is no longer a killer as long it is treated appropriately. In the UK it can now be managed and does not need to be life threatening. “It has gone from an acute illness to a chronic illness” “You used to die - and now it is taking a daily tablet.” In addition to being a sexually transmitted disease, it was understood that HIV could be transmitted by blood transfusions and by shared needles.

c) The image of HIV- and the stigma There is still a stigma around HIV which is seen to be partially “fuelled” by a lack of understanding of the disease. People don’t talk about it there is a sense in which it is seen to be a “dirty” disease.

“If you say you have HIV you get a totally different reaction to if you say you have cancer. It is seen as a dirty disease and people look at you.”

This perception of HIV being a dirty disease can lead to reluctance for individuals to have an open conversation about HIV and prevention.

Who is most at risk?

There was considerable debate over who is most at risk and the general consensus was that although gay men are high risk everyone is at risk and especially young people. Risk is attributable to ignorance and the lack of awareness of HIV among adults and the lack of relevant education among young people. In particular, although HIV is seen as a gay disease, it is known that white, heterosexuals are also at risk but are not aware of that risk.

“Heterosexuals seem to be totally unaware of HIV, how serious it can be and to ignore simple precautions”

“All the straight guys I know are have unprotected sex. They think protection is only about pregnancy.”

The level of ignorance and risk is raised further by advertising and promotion of bareback sex as “the thing to do” and by the failure of condom manufacturers to promote safer sex.

“People that visit various sites that promote bareback sex are at risk because they believe it is ok. They are ignorant.”

4.3.4 How can the spread of HIV be prevented? Respondents identified three key ways of preventing the spread of HIV – all of which reflect the perception that HIV is principally a sexually transmitted disease. They are:

- Abstinence “The best way is just not to – but that isn’t realistic!”
- Using protection during sex (such as condom) “We should all use condoms but advertising tells you not to”
- Protecting yourself by insisting that any new partner has a test before having sex with them. “Gay men go automatically for a check up.” 4.3.5 Searching for information relating to sexual health and HIV

Searching for the information There are a number of different ways in which individuals will look for general information relating to sexual health and HIV. The most popular and common is to use the internet and the Google search engine. It is private, convenient and confidential.

“The easiest thing is to Google it” However, participants also talk of finding information in others ways including reading leaflets and posters that are available in GP surgeries, public toilets and some clubs, calling NHS Direct and visiting STI clinics.

“Sexual health clinics are good though.”

Which sources of information are trusted? Individuals talked of the need to be able to trust any sources of information about HIV and there was a high degree of trust placed in information obtained via the internet and from Sexual Health Clinics.

Aside from these two sources of information, other trusted sources are those who are specialist / experts or people who have an intimate knowledge of the situations an individual may be facing. These include specialist organisations such as THT or NAT and people who may be living with HIV and AIDS.

“I want to get information that is personal to me. It needs to come from an expert; a specialist “You need to think - who is going to tell you the truth? When you answer that, you know who to trust” “It helps if there is research that backs things up – a clinical study etc.”

GPs and local community based organisations are generally not trusted as they are not seen to have the level of knowledge / expertise that is required.

“GPs judge you – and you don’t need that.”

Key considerations when looking for information There are three key considerations when looking for information and support:

- Confidentiality
- Privacy
- Credibility of the source of information.

“I only visit clinics that are out of area to maintain my confidentiality though it can be difficult to find out where they are located unless you Google them.”

“Confidentiality is more important to me than convenience”

“It takes an expert to be credible otherwise people are just the words they have been told to say!” Access to condoms

All participants talked of how easy it is to get access to free condoms through STI clinics, pubs and clubs. While the quality of these condoms might not be as high as those bought in pharmacies, these concerns were overcome by the ease of availability and the fact that they are free.

“Supplies of condoms need to be easy to find and in places where you can go in, take them and walk out with no questions. It works well in clubs but other places aren’t as easy.”

“I sometimes get a girl friend to get some for me if I think I have taken too many.”

Lube is purchased from pharmacies or on-line from Amazon.

4.3.6 Delivering specific messages in relation to HIV and HIV prevention

What specific messages are relevant to HIV and HIV prevention in particular?

There was general agreement that there is a key message that needs to be shared with everyone. That message is “anyone can get HIV and AIDS and these are the consequences”. The message needs to be direct and to the point and leave no one in any doubt about the consequences and how serious it can be. The message needs to be a wakeup call for everyone not specific to the gay community.

“HIV is a big deal and people need continuous reminders from responsible voices”

“It is important to get the message across that AIDS is a risk to everyone. You might need to scare people”

“People really need to see it (the message) they need to see that you are not skinny and drawn. That you could walk past someone in the street with HIV or AIDS”

“I remember burying a friend of mine who had passed away – I remember thinking that he died because he had sex just once. That is all it took. That is the message”

“It should be saying it is life threatening.”

There was also considerable discussion on what messages need to be conveyed to encourage people to prevent the transmission of HIV. Thoughts included:

“People need to understand the consequences; that prevention is the only thing that will make a difference”

“Education in schools needs to be made real and relate to today’s world and why HIV needs to be prevented”

“Engage condom manufacturers in the prevention messages.” Who should communicate the messages? Who has trust, credibility and recognition?

It was generally agreed that it is important to have an overall national awareness programme with information provided by a “trusted” organisation such as the NHS. This would give the campaign credibility and would generate trust in any information that is conveyed as part of the campaign. A general campaign could be supported by local organisations (local NHS and specialist HIV organisations) but the importance of having a consistent, national message was stressed.

Consideration was given to the different organisations that could communicate the messages. Overall, it was felt that it is important for the organisations to be seen to have the expertise and knowledge of health, HIV and sexual health – i.e. they are communicating as experts rather than acting as mere channels of communication. Comments on specific organisations included:

a) National organisations • NHS is a trusted organisation and as long as the NHS logo was on materials that would be sufficient • “As long as it has the NHS logo it is fine. After all it is the National Health Service” • Despite its association with the NHS, NHS Direct was not seen to be credible. It is perceived to be staffed by receptionists who would not have the depth of knowledge required • NHS Choices was not recognised and therefore not trusted • Dr. Thom was not recognised and therefore not trusted • The Department of Health is a trusted organisation and known for their key public health campaigns. However they are associated with many other public health campaigns and there are concerns that the messages could become confused and diluted • Public Health England was not recognised and therefore not trusted • HIV Prevention England – no-one had heard of it though a number commented positively on the name and felt that it could probably be trusted • Gov.uk as an organisation is too associated with other issues such as benefits, tax etc.

b) Local public sector organisations • Local authorities are not considered to be an appropriate or credible channel of communication. All Local Authorities are seen to have differing priorities and that may or may not include HIV prevention. This means that there would be no guarantee that a consistent message is conveyed to everyone. It was also noted that Local Authorities are more associated with Council Tax and bins rather than health and this could lead to problems over credibility • Local NHS organisations are recognised and seen to be credible. They could act as a valuable support to a national programme. It is preferable to have a regional rather than local campaign to ensure consistency of message and to avoid local interpretation of the message or excessive influence of local priorities. c) **Local third sector organisations**

- THT and NAT are trusted and credible within the gay community. However if they are the only organisation involved in delivering prevention messages, there is a danger of perpetuating the concept that HIV and AIDS is a gay disease.
- Stonewall was not seen as credible as it is perceived to be one gay man’s perspective.
- Concerns were raised over the use of local community groups due partially to a lack of awareness of many of the groups but also due to the perception that they “could not possibly have the expertise and knowledge required”. They were not seen as credible sources of information.

d) **Other local organisations**

There was generally a negative reaction to the idea of information on HIV being channelled through supermarkets or pharmacies unless it was by displaying leaflets. These organisations have no expertise and therefore no credibility in the area and would not be widely trusted.

**What is the best way of getting the messages across?**

It was widely acknowledged that it is difficult to get messages across in what is an already “crowded” market place. Any messages relating to HIV prevention would have to compete with a wide range of other messages that range from free offers to claiming PPI insurance.

Individuals agreed that this means that the message has to be direct and to the point. Importantly it needs to use different media depending on the nature of the messages and the target audience. There is also a difference between needing to raise awareness among the adult population and among young people.

a) **Raising awareness among the adult population**

Raising awareness among the general population was considered to be essential with messages being relevant, appropriate and accessible. Importantly, it was felt that the most appropriate ways of getting the message across is to put the messages in a “contained space” where individuals have time to read and absorb the message. Suggestions included:

- Something London wide on the tube where you have time to read
- Metro
- Leaflets in pharmacies
- Pop-ups on relevant websites
- Advertising on condoms (“Durex have a responsibility”)
- You-Tube.

b) **Raising awareness among young people**

Concerns were raised over the extent to which young people are made aware of HIV and ways in which it can be prevented. All groups agreed that young people are most at risk because of their ignorance and that it is important to get the message across through an education programme in schools as well as by encouraging parents to talk about HIV. What channels of communication would alienate?

There are a number of means of communication that would alienate individuals and that could have a negative impact on them. These included:

- Someone coming to the door to talk about HIV and prevention
- Text / phone calls as there are so many unsolicited texts / phone calls
- A physical letter that would be seen as junk mail or even could be embarrassing and cause difficulties in a relationship
- Using focused leaflets / information that are perceived to stigmatise alienate/discriminate against a segment of the community. There were two elements to this concern.

Firstly, where materials only focus on a particular community (e.g. the gay community) it can potentially lead to discrimination within the wider community.

“Using gay focus leaflets just means that everyone goes on thinking it is a gay disease”

“It makes people believe that because I am gay I will have HIV. What about everyone else that has it?”

Secondly, there are segments of the gay community that would be “untouched” by the awareness raising materials and not have the benefit of the education and knowledge that participants agreed was essential.

“The gay community is much larger than the community depicted on existing materials. It covers people that still haven’t come out and people living in heterosexual relationship. Some of the leaflets that are produced seem to be designed to alienate those groups.”

- Using something that is distasteful or even considered to be pornographic “Come away from the place of it being distasteful and inappropriate.”

4.3.7 Comments on previous campaigns and materials

There was little or no recall of specific HIV campaigns in the UK with the exception of the 1980s “tombstone campaign”. Looking at the existing publicity materials drew comment and criticism.

- There was concern that they were so focused on the gay community “These are useful but they are aimed at gay spaces and there are a lot of gay people that don’t go to the gay spaces. How would they access this information?”

- Some of the material was seen as inappropriate and even offensive which restricted significantly they the locations in which it could be placed as well as limiting the audience. “Some of these things are offensive but they should be capable of being read by everyone” “You don’t have to make HIV seedy, you don’t have to show it in a pornographic way. Some of these are really inappropriate” “You need to come away from a place of it being distasteful and inappropriate to a place where it will be read and understood.” 5 Findings: Black African

Although the groups were composed of individuals from a number of different African countries, it was notable that the responses within the groups were very similar irrespective of country / region of origin, so all responses have been grouped together in this report. Where there were some limited differences between the female and male groups this has been highlighted below.

5.1 Focus group participants

| West African women focus group – 13 participants | |-----------------------------------------------| | Age | | Range: 25 – 44 | | 3 20s, 7 30s, 3 40s | | UK or African born | | 7 UK born, 6 Africa born | | Country of origin | | 4 Nigeria, 4 Ghana, 2 Gambia, 2 Sierra Leone, 1 Ivory Coast | | Boroughs | | 3 Barking & Dagenham, 2 Newham, 2 Hackney, 1 Greenwich, 1 Lambeth, 1 Tower Hamlets, 1 Brent, 1 Southwark, 1 Islington |

| West African men focus group – 14 participants | |-----------------------------------------------| | Age | | Range: 25 – 41 | | 4 20s, 8 30s, 2 40s | | UK or African born | | 7 UK born, 7 Africa born | | Country of origin | | 4 Nigeria, 4 Ghana, 2 Gambia, 2 Sierra Leone, 2 Cameroon | | Boroughs | | 4 Lewisham, 3 Barking & Dagenham, 3 Enfield, 2 Haringey, 1 Southwark, 1 Greenwich |

### South African women focus group – 6 participants

| Age | Range: 25 – 44\
| | 3 20s, 2 30s, 1 40s | | UK or African born | 5 UK born, 1 Africa born | | Country of origin | 2 Zambia, 2 South Africa, 1 Zimbabwe, 1 Swaziland | | Boroughs | 1 Southwark, 2 Waltham Forest, 3 Newham |

### South African men focus group – 8 participants

| Age | Range: 25 – 44\
| | 4 20s, 1 30s, 3 40s | | UK or African born | 4 UK born, 4 Africa born | | Country of origin | 4 Zimbabwe, 2 Zambia, 1 South Africa, 1 Malawi | | Boroughs | 2 Greenwich, 2 Barnet, 2 Southwark, 1 Redbridge, 1 Barking |

### East African men focus group – 12 participants

| Age | Range: 22 - 43\
| | 4 20s, 5 30s, 3 40s | | UK or African born | 5 UK born, 7 Africa born | | Country of origin | 4 Uganda, 2 Kenya, 2 Tanzania, 2 Somalia, 1 Ethiopia, 1 Eritrea | | Boroughs | 6 Enfield, 4 Barking and Dagenham, 1 Barnet, 1 Haringey | 5.2 Key findings

5.2.1 Accessing information

- Individuals use a wide range of broadcast, print and online media to access general information. This includes free media (Metro and Evening Standard) and paid media (daily newspapers) as well as online information available through free apps
- Many individuals access additional information through the BBC News website
- ‘Black media’: Very few individuals use UK ‘black media’ like The Voice but a significant number of individuals access media that is specific to their community or culture ‘back home’ (media based in Africa and UK based media that focuses on African affairs such as the Africa channel). This can include newspapers, websites and TV channels. The key reasons for this are to understand what is happening “back home” as well as to have stronger links with events that are taking place within specific communities.

5.2.2 Health priorities

- The key health priorities are healthy living and fitness – something that was common to all of the groups and both genders
- Health priorities are influenced by family history, getting older, a “wake up call” (usually as the result of personal illness or illness of friends and family) and fear of becoming ill
- For many, sexual health is a priority and the majority of women and some of the men attend the Sexual Health Clinic on a regular basis where they are regularly tested for HIV. In addition, men born and brought up in Africa talked of being tested prior to marriage – something that is a legal requirement in some countries.

5.2.3 Awareness / knowledge about HIV and other STIs

- Awareness and knowledge of HIV varies considerably between gender and country of birth.

  - **High awareness:** Knowledge and awareness of HIV is high among individuals both male and female born outside the UK. This is attributed to the education and awareness programmes in Africa along with an “openness” about HIV. Female participants born in the UK also have high levels of awareness
  - **Low awareness:** Among UK born male participants, levels of awareness and knowledge are much lower with a number believing HIV to be a gay disease and something that will not touch them.

- It is generally recognised that HIV is a sexually transmitted disease and also that it can be transmitted by blood transfusions and by shared needles

- Individuals are aware that there are ways in which they can protect themselves through use of condoms and ensuring that any potential partners have been tested before entering into a sexual relationship

- There is concern among all respondents that the same levels of awareness and openness that exist in Africa are not evident in the UK. Younger people in particular are seen to be at risk because of the lack of awareness and understanding of the impact of HIV

- There is a perceived need to raise awareness among the whole population and especially young people.

5.2.4 The extent to which HIV is an issue for individuals

- It was generally acknowledged that HIV transmission can be limited or even prevented by, using a condom or ensuring that partners are “clear” and that this is proved by testing
- HIV is an issue and a concern but the severity of the impact can depend on gender and on whether individuals were born in the UK or in Africa
  - **Females:** For the majority of females, HIV is a concern – as is any STI. Consequently, the majority of female participants ask potential partners to be tested prior to engaging in sexual relationships
  - **Males born in Africa:** For the majority of male participants born in Africa, HIV is an issue that they have been “brought up with” and know they need to deal with. Consequently, the majority, but not all of them use condoms and are tested on a regular basis
  - **Males born in UK:** A number of male participants born in the UK talked of only using condoms as a contraceptive device not as a preventative measure against HIV. There was a perception that HIV would not touch them.

5.2.5 Sources of information, advice and support on sexual health / HIV

- The key source of information on sexual health and HIV is the internet although some individuals, and especially women, will search for information through GP surgeries, Sexual Health Clinics and calling NHS Direct
- In terms of the internet, Google is the preferred search engine and the results and information obtained are generally found to be helpful and credible. A number of male participants felt that it is easy to see how helpful the information has been to other users and that this gives a degree of confidence and trust
- Two of the groups (female from South Africa and male from East Africa) also highlighted the fact that a number of TV channels, and notably Channel 4, have some helpful and insightful programmes covering issues such as sexual health. It was felt that the information given on such programmes could be trusted as they are presented by specialist and experts.

5.2.6 The health / HIV services used by individuals

- Individuals talked of using a range of different services with the most common being Sexual Health Clinics. Some participants (predominantly female) also used their GPs to talk to about their sexual health
- Individuals do not consider pharmacies to have the relevant expertise to help and some of the women were concerned at possible lack of confidentiality.

5.2.7 What key messages should be delivered?

- All participants, irrespective of where they are from or gender agreed that the most important message to be delivered is that HIV can affect anyone. Further, everyone needs to understand the implications of getting HIV and how to prevent it

- All participants also felt that the message should be designed to shock and make people stop, think and take action

- Many participants, and the females in particular, felt that HIV should be “grouped” with other STIs and that it would be helpful to stop making it a special case. All STIs are seen to be devastating in one way or another

- They also believed that it is important for the message to reach out beyond the Black African community into the wider community and especially white heterosexuals and young people

- Given their desire to extend awareness into the wider community, participants agreed that it is not appropriate to use awareness raising materials that focus specifically on the Black African communities. This is seen to be discriminatory and potentially will isolate members of the community.

5.2.8 Channels of communications

- All of the participants agreed that messages should be delivered through a coordinated campaign that has a national and local focus
- It was felt that the channels of communication used should allow individuals to read and absorb the message at a time and place that suits them
- They also believe that it is important that whatever channels are used, they are accessible to everyone i.e. the whole community. These could include:
  - TV / cinema advertising
  - Bus back
  - On the underground
  - You Tube
  - Metro / Evening Standard
  - Leaflets in relevant places
  - Education programmes in schools.
- A number of ways of communicating different messages in relation to HIV were felt to be inappropriate which included text / phone calls, physical letters and leaflets that discriminate against particular groups within the community
- Particular reference was made in all of the groups to only using black faces on leaflets and other materials. This is seen to be discriminatory and to promote a negative image of the Black African community. It was stated that the impact could be that any such information would just be ignored. While all groups / genders reacted negatively to black only images, this was especially true of the male groups.

5.2.9 Who / what are credible sources of information?

- All of the groups felt that messages should be seen to come from a credible and a trusted source. These include:

  - NHS organisations at national and regional level – with the importance of the logo being stressed
  - Department of Health.

- Local Authorities are not considered to be credible as they are too closely associated with provision of Council Services and the extent to which they can be specialists and knowledgeable about HIV is questionable. There were also concerns that some Local Authorities would not prioritise awareness programmes and there would be sections of the population that would “miss out”

- It was felt that local community groups would not have the relevant expertise and experience unless they were staffed by healthcare professionals.

5.2.10 How important is confidentiality, convenience and credibility

- Individuals in all of the groups talked of the importance of confidentiality when seeking information on HIV and sexual health. This was given as one of the main reasons for the extensive use of the Internet
- A number of individual participants, and in particular women, talked of going to STI clinics and other health services outside their local area in order to maintain confidentiality despite any inconvenience this may cause
- Male participants from East Africa felt that information relating to HIV and sexual health should be given by healthcare professionals who are Black Africans and who understand the range of other, different illnesses that are found among the Black African community. 5.3 Detailed findings

5.3.1 Use of different media to access information Respondents talked of accessing information using a range of different media according to the nature of the information / support required. This includes broadcast media, print and on-line information services. Similar responses were received in all of the groups irrespective of gender or country of birth.

- There is widespread readership of a range of UK based daily newspapers with some individuals choosing to read newspapers online via a tablet or phone while others prefer “holding the paper”
- All read Metro and / or Evening Standard “When I am on the train in the morning I always pick up the Metro” (West African female)
- The majority look at the BBC News website at some point during the day “I usually go on line and look at the news throughout the day” (South African male)
- Individuals listen to a range of mainstream radio stations during the day such as Magic, Choice FM.

In addition, a number of individuals talked of accessing media that is specific to their community or culture “back home”. This included specific African / Muslim TV channels such as Al Jazeera, ENCN (South Africa) and the Africa Channel (BBC) as well as publications such as the Zambia Daily Mail which can be read online or in news print. The key reasons for accessing these different media relate to a desire to find out what is going on “back home” or that relate to things that are happening to people in my community.

“It is important to get Muslim news and Al Jazeera is the best for that.” (South African male)

Very few individuals knew of or read UK based ‘black media’ like The Voice - price of this media can also be a barrier to use.

“I used to buy the Voice but haven’t for ages. It is so expensive (at £1.20).” (South African Female)

5.3.2 Attitudes to overall health Health and well-being are both considered to be very important – and for some it is more important than money. There is little difference between the different cultural or gender groups.

“I see why I need to be healthy if I can be” (South African female) “I am conscious that I come from a culture that has significant numbers of health issues (especially diabetes) and I know health is a priority!” (West African female) “Health is the most important thing- even more than money.” (South African male)

However, despite the fact that individuals may feel that their health is important, they don’t always take the action they know they should take to keep themselves healthy and fit. “Knowing what you ought to doesn’t always doesn’t make you do it.” (West African male)

There are a number of factors that influence the extent to which health is a priority and will encourage individuals to take action. These include:

- A family history of chronic conditions such as diabetes “I was threatened by Grandma over diabetes and high blood pressure. Saw what it did to her and know I don’t want diabetes!” (West African female)

- Coming from a culture that has a significant numbers of health issues that are known to originate in lifestyle “When I go home, eating is a nightmare. I have to eat everything that is put in front of me – and who knows what that is!” (East African male)

- Getting older “Health is more important the older you get; I want to be around for longer and see children and grandchildren” (West African female) “When you get to a certain age you tend to worry more” (South African female) “As I get older I start to think about my health and wanting to be here” (South African male)

- Fear of becoming ill “I wouldn’t say I worry but I know that being sick slows you down during the day. If I can prevent being ill I will do something” (South African female)

- A personal “wake up call” through a personal illness or illness of a friend / family member “But the only way I would do something …. is if my health was affected or someone close to me was affected” (East African male) “In the past eight months I have been ill and I realise just how important health is” (West African female) “When I saw my mum die, I realised I didn’t want to die early and to see my children and my children’s children. So I have taken action about my health” (South African female)

- Concern about sexual health “I was born in Zambia and it is second nature to be concerned about your sexual health and to take action” (East African Male) “I worry about my sexual health and know I need to take action when going into a new relationship.” (West African female)

5.3.3 Knowledge of and attitudes to HIV and AIDS

Overall awareness, perceptions of HIV and how it is transmitted

a) Levels of awareness There were varying levels of awareness and knowledge of HIV across the different groups. Black Africans born outside the UK felt that their level of knowledge and awareness of HIV is considerably higher than that of British Black African, white British heterosexuals and other ethnic groups. This was attributed to education and the open way in which HIV is talked about in all countries in Africa. This difference in awareness and understanding was particularly noticeable in the South African male group although it was evident in the other groups too. Those born in Africa were much more aware of the issues, the risks and treatments while those born in the UK felt that this was not a disease that would touch them. Some of this lack of awareness was attributed to the information that is being given out by STI clinics.

“In the UK they are just complacent and don’t really know anything” (East African male)

“In school in Zambia, the mantra was use a condom so you don’t get AIDS and it was drummed into us. At school here, my kids are not even told about it” (East African male)

“At home you come out of the airport and there is a billboard telling you all about HIV. Where is the advertising in England? It is little wonder British people don’t know” (South African male)

“In the clinics here they tell you as long as you were born in the UK you don’t need to worry – but they don’t really tell you any more than that” (South African male)

“Even the messages that the clinics give out can be misleading. You are asked where you partner is from and you say here. The clinic will say you are not at risk.” (South African male)

Participants born / brought up in Africa noted that the lack of awareness among British Black African, white British heterosexuals and other ethnic groups is a function of the lack of education in schools, advertising and general awareness-raising. This is seen to have had a significant impact on levels of knowledge. At the same time, it was acknowledged that information is available – but just not that accessible. People don’t know where to look.

“Some of the information out there is amazing – so that if someone has been exposed to someone with HIV as long as they take a pill they will be OK. But no-one really knows about it - the information needs to be out there more.” (South African female)

b) What is HIV and how serious is it?

It was acknowledged by everyone that HIV is a serious condition and can ultimately be life threatening. It is generally thought to be a sexually transmitted disease that can affect anyone and everyone.

“It is a sexually transmitted disease that you get from having sex. It can affect anyone” (South African female)

“It is incurable. I had a cousin who died of AIDS; they could not cure him,” (South African male)

“HIV isn’t one of those diseases you live with – it is death.” (East African male)

At the same time, a number of individuals recognised that treatments have improved over the years and that HIV / AIDS is no longer a killer as long it is treated appropriately. In the UK it can now be managed and does not need to be life threatening but it was noted by all groups / genders that this is not the case in many African countries.

“It has got better” (South African male)

“I know it can be tackled and controlled but think it grows into AIDS if it is not tackled.” (South African female) However, the impact of having HIV is seen to be considerable - both in the way it can affect an individual psychologically and in the way they may be viewed by society.

“The impact is serious on mental state. You are living with a time bomb and have to decide whether to get revenge or how to live with the stigma” (West African female)

“Just hearing the news alone you would be in bits” (West African female)

“Cancer gets sympathy; HIV the reaction is that you did it to yourself and you don’t deserve help” (East African male)

“When you look at the person you don’t want to approach them because you are afraid” (West African female)

“The minute you say (to a girl) that you are from South Africa people are afraid to know you. They assume that you will give it (HIV) to them” (South African male)

“I won’t lie I was influenced (negatively) by the fact that someone had HIV.” (West African female)

c) The image of HIV and a stigma

There is still a stigma around HIV which is seen to be partially “fuelled” by the secrecy that surrounds HIV in the UK. Many of the participants born outside the UK felt that people don’t talk about the true scale of the illness and there is a sense in which it is seen to be a “dirty” disease.

“It is much more secretive here in the UK than in Africa; there everyone talks about it” (South African male)

“Although it is a sexually transmitted disease, it is always put in another box which somehow makes it feel worse” (South African female)

“There is still a “skull and crossbones” associated with HIV and you want to avoid that.” (South African female)

“You feel ashamed to talk about it here. At home everyone knows who has HIV but it is a small community.” (East African male)

d) Transmission of HIV

Participants in all of the groups highlighted the fact that HIV is a sexually transmitted disease and that it can also be transmitted by blood transfusions and by shared needles.

Who is most at risk?

There was considerable debate over who is most at risk and the general consensus was that everyone is at risk and especially young people. Risk is attributable to ignorance and the lack of awareness of HIV among adults and the lack of relevant education among young people. This response was true for both genders, irrespective of country of birth.

“There is so much ignorance in this country and people don’t believe that everyone is at risk” (West African female)

“How can people know they are at risk when they don’t understand what it is?” (West African male)

“Young people don’t understand the importance of getting checked when you are in a relationship” (South African female)

“Young people think they have more chance of catching STIs than HIV. They should be put on the same level” (South African Female) “Young people have no idea and there is no proper education for them in schools” (East African male) “Young people see advertising that says unprotected sex is best – and they believe it.” (East African male)

A number of individuals acknowledged that HIV is seen as a gay disease and that Black Africans are also seen to be a high-risk group. However, there was a lot of concern over these perceptions and suspicion over the statistics that support these statements. There is a sense that white, heterosexuals are just as much as risk as but there is no publicity and the research is not really carried out.

“Some people in the UK think it is only Africans that have AIDS. They say that we don’t have AIDS in the UK” (West African female) “We don’t see the (white) statistics; it is never talked about.” (South African female)

How can the spread of HIV be prevented?

Given that the majority of respondents identified the fact that HIV is a sexually transmitted disease, there are two key ways of preventing the spread of HIV “Using protection during sex (such as a condom)” “Using a condom is what you must do (East African male) Protecting yourself by insisting that any new partner has a test before having sex with them “I just won’t go into a new relationship until they have had a test.” (West African female)

5.3.4 Searching for information relating to sexual health and HIV

Searching for the information

There are a number of different ways in which individuals search for information relating to sexual health and HIV. The most common and popular is to use the internet and the Google search engine. It is private, convenient and confidential. Some men in each group also noted that it is hard to know where to go for information in the UK while in Africa they know exactly where to turn for relevant and appropriate information.

“It is the one place you know you will find information. Where else do you go?” (East African male) “Online is the first port of call because it is private. I start there and then check out the information” (West African male). “It is a start point and can help you think through who else you could ask” (South African female) “It helps you think what questions to ask without looking silly” (East African male) “It is intimate. You go to the GP and the receptionist asks you in front of everyone what is wrong with you.” (West African female) Participants also talked of using other sources of information including leaflets in GP surgeries, calling NHS Direct and visiting STI clinics.

“GPs have leaflets on HIV and STIs. You can just go in a take one” (West African male) “GPs have stuff on the wall too which is quite good. You can just read it without being obvious” (South African female) “You can pick up leaflets at GPs which have phone numbers that you can contact if you are worried (didn’t know what the phone numbers were).” (South African male)

It was noted by a number of participants, and in particular females, that it is preferable to visit clinics that are out of area and that it can be difficult to find out where they are located unless you Google them.

Which sources of information are trusted?

All groups talked of the need to be able to trust the different sources of information and there was a high degree of trust placed in information obtained via the internet and from relevant TV programmes.

“The good thing about Google is that you can see who else feels this is information that you can trust. And then you believe it” (East African male) “Channel 4 has some fantastic programmes – and you trust the information they have because it comes from experts” (South African female) “A great source of information is Channel 4 and their sex education programmes. They always have links at the end so when you see something that is concerning for you, you immediately know where to go. That is the problem; knowing where to go.” (East African male)

Apart from the internet and TV, the most trusted sources of information are seen to be specialist / experts; people who have an intimate knowledge of the situations an individual may be facing. These include:

- Sexual Health Clinics
- Specialist organisations
- A&E – if the person had recently been exposed to HIV
- People who may be living with HIV and AIDS.

“The family Planning Clinic / STD Clinic are the best because they know what they are talking about” (West African male) “I want to consult people who know what they are talking about” (South African female) “You need to hear information from people and you can see how ill they are. But it is important that it looks like someone I know” (South African female)

GPs, churches and community based organisations are generally not trusted as they are not seen to have the level of knowledge / expertise that is required. The male groups were particularly concerned about information channelled through local churches while the female groups were more concerned about lack of confidentiality at local pharmacies and local community groups.

“GPs are not it” (East African male) “If you went to the church the Pastor would just try to heal you not help you” (South African male) “I wouldn’t go to a pharmacy – ‘cos they don’t always know what they are talking about and you would have to explain over the counter what you want” (West African female) “It is so much easier if you don’t know the person you are talking to.” (East African male)

At the same time however, a number of men talked of the value of getting support and advice from professionals from their own community.

“I want Black advice on these subjects because they will understand your illnesses and not ask the stupid questions because they don’t understand our health issues.” (South African male)

Key considerations when looking for information

All groups talked about three key considerations when looking for information and support. These were confidentiality, privacy and credibility of the source of information:

• Individuals in all of the groups, irrespective of gender or country of birth talked of the importance of confidentiality when seeking information on HIV and sexual health. This was given as one of the main reasons for the extensive use of the Internet • A number of individual participants, and especially females, talked of going to STI clinics and other health services outside their local area in order to maintain confidentiality despite any inconvenience this may cause • Credibility is key. As outlined above, some participants felt that information relating to HIV and sexual health should be given by healthcare professionals who are Black Africans and who understand the range of other, different illness that are found among the Black African community.

Access to condoms

With the exception of the East African male group, all participants talked of how easy it is to get access to free condoms through STI clinics, pubs, clubs and some community centres. While the quality might not be as high as those bought in pharmacies, this was overcome by the ease of availability and the fact that they are free.

“Condoms need to be in places where people can just go in, collect and not be asked questions. You are probably not in a state of mind to read a leaflet / talk to someone if you want condoms!” (East African male) “I sometimes worry that they are not good quality and might break but at least they are free” (South African male) “I always go to the clinic and just take a handful” (South African male) “Why would I go anywhere else” (West African male) “I have a great app that shows me where I can find free condoms close to where I am!” (South African female) The East African group reported that they are unable to get support from the STI clinic free of charge as they are the “wrong age” (they are too old) They will buy condoms as cheaply as possible from pharmacies, machines in public toilets and service stations.

5.3.5 Delivering specific messages in relation to HIV and HIV prevention

What specific messages are relevant to HIV and HIV prevention in particular?

There was general agreement across all of the groups that there is a key message that needs to be shared with everyone. That message is “anyone can get HIV and AIDS and these are the consequences”. The message needs to be direct and to the point and leave no one in any doubt about the consequences and how serious it can be.

“HIV is a big deal and people need continuous reminders from responsible voices” (West African female)

“It is important to get the message across that AIDS is a risk to everyone. You might need to scare people” (East African male)

“Put it on the same level as STI as people will take it more seriously. It will be more relevant” (South African male)

“Let people know the implications of sleeping with someone and the fact that you could be sleeping with “thousands” of others” (South African Female)

“Anyone can get AIDS – they should have a line-up of people and ask them who has AIDS and someone I know.” (West African female)

It is also seen to be important to consider HIV along with other STIs - as all can be equally devastating and prevention means are very similar or the same.

“People differentiate between HIV and STDs and yet prevention is the same and the impact of other STDs can be just as devastating (infertility). Should combine the different diseases and talk about all of them together.” (South African female)

Channels of communication - Who has trust, credibility and recognition?

It was generally agreed that it is important to have an overall national awareness programme with information provided by a “trusted” organisation such as the NHS. All participants felt the NHS would give the campaign credibility and would generate trust in the information that is conveyed as part of the campaign. This could be supported by local organisations (again NHS and specialist HIV organisations). But it is important to have an overarching, national message to everyone. More detailed responses were given on the different organisations that could communicate the messages. These were as follows:

a) National organisations • NHS –a trusted organisation and as long as the NHS logo was on materials that would be sufficient. Further there was no differentiation between national and local organisations “As long as it has the NHS logo it is fine” (West African female) “That would build trust as it recognises that HIV can affect everyone.” (South African male)

- Department of Health – are a trusted organisation but are associated with many other public health campaigns and there are concerns that the messages could become confused
- Public Health England – no one had heard of it
- HIV Prevention England – no-one had heard of it though a number commented positively on the name
- Gov.uk – too associated with other issues such as benefits, tax etc.

b) Local public sector organisations

- Local authorities – not considered to be appropriate as there are no guarantees of consistency and it is important that a consistent message is conveyed to everyone. All Local Authorities are seen to have differing priorities and that may or may not include HIV prevention. Further they are seen to be associated with council tax and bins not health
- Local / regional NHS are seen to be credible and messages from them could provide valuable and consistent support to a national programme.

c) Local third sector organisations

- Local organisations should only support a national programme – not deliver the programme themselves. Thoughts on different organisations were:
  - Local STI clinics – would be trusted and be credible “They are the experts” (West African female)
  - Local community groups – there is a lack of awareness of many of the community groups and therefore a concern as to how relevant they would be. At the same time there was recognition that such groups could have local information relating to the different cultures /lifestyles within the area that could be relevant. It also depends on the sort of information that would be disseminated by these organisations and the level of support. It was felt that smaller charities would not necessarily have the expertise but might be better at overall well-being.

d) Other local organisations

- Across all the groups there was a negative reaction to the idea of information on HIV being provided by supermarkets or pharmacies unless it was by displaying leaflets. These organisations have no credibility and would not be widely trusted
- Concerns over confidentiality were also expressed if information / condoms etc are handed out in local shops, hairdressers etc. Again it might be possible to display leaflets but it would be important to ensure that these could be picked up discretely.

What is the best way of getting the messages across?

All groups acknowledged that it is difficult to get messages across in what is already “crowded” market place. Messages relating to HIV prevention would have to compete with other messages ranging from other healthcare issues (such as diabetes) to free offers. This means that the message has to be direct and to the point. Importantly it needs to use different media depending on the nature of the messages and the target audience. There is also a difference between needing to raise awareness among the adult population and among young people.

a) Raising awareness among the adult population Raising awareness among the general population is considered to be essential with messages being relevant, appropriate and accessible. Importantly, it was felt that the most appropriate way of getting the message across is to put the messages in a “contained, private space” so that an individual can read and absorb. Suggestions included:

- TV / cinema advertising
- Bus backs where a key message can be read easily and privately
- On the underground
- In the Metro / Evening Standard
- You-Tube
- Leaflets in relevant places such as libraries, gyms and GP surgeries but avoiding more “public” places such as hairdressers
  - “Put leaflets in relevant places” (West African female)
  - “Places that are a little more anonymous if you want to pick one up” (South African male)
- For some (and especially women) it was felt that a letter from the PCT would be appropriate as this is similar to the letters they receive about cancer screening and therefore would be taken seriously.

b) Raising awareness among young people Concerns were raised over the extent to which young people are made aware of HIV and ways in which it can be prevented. All groups agreed that young people are most at risk because of their ignorance and that it is important to get the message across through an education programme in schools as well as by encouraging parents to talk about HIV.

What channels of communication would alienate? There are a number of means of communication that would alienate individuals and that could have a negative impact on them. These included:

- Someone coming to the door to talk about it (all groups)
- Text / phone calls as “I get so many unsolicited texts / phone calls” (all groups but stronger in female groups)
- A physical letter that would be seen as junk mail or could be embarrassing and cause difficulties in a relationship (particularly true of male groups)
- Using leaflets that stigmatise a particular group or community.
  - “If I saw leaflets that only had black faces on it I would think it was discrimination. You are telling the world that we are bad so why would I listen?” (East African male)
  - “In the UK god is always white and the devil black. If you show black faces with something like HIV that means that we are the devil” (West African male) • Using leaflets / information that alienates a segment of the community such as using the wrong “African” faces on materials. All groups commented on this as an issue but it was particularly strong in the male groups.

“It is really important to understand the difference between the different African groups and even between those born in the UK and in Africa. We all look different – so who are they aiming it at?” (South African male)

5.3.6 Comments on previous campaigns and materials There was little or no recall of specific HIV campaigns in the UK with the exception of the 1980s “tombstone campaign”. Many of those born / brought up in Africa were aware of billboard campaigns and schools campaigns they had seen there and were able to recall the message that HIV kills.

In addition, there was some recall among the women of the UK Chlamydia TV campaign.

6 Discussion

Limitations This research has generated significant insight into the target groups’ preferences around sexual health services and receiving HIV prevention. But being focus groups with a limited number of participants (particularly gay men with whom there was only one group) the research is not generalisable across the whole of these populations. In addition, since participants in focus groups are self-selecting (both in agreeing to participate and actually choosing to attend) there could be non-participation bias. Bias can also be introduced through the group nature of the research with cross influence of shared thoughts and ideas.

It is also recognised that behaviours recorded from the groups are self-reported so may not reflect what the participants actually do. However, the focus groups do give an effective picture of the participants’ perceptions. Researcher bias is also possible in this study since just one individual collected the data, but this has been mitigated by three researchers being involved in the analysis.

Awareness of HIV Awareness of HIV was found to be higher among gay men and those from the black African groups who were born in Africa than among British born ‘black Africans’.

Gay men recognised they are at higher risk than other groups but felt that other groups are also at risk but unaware of their own risk. Black Africans generally thought their level of risk was on par with other groups.

However, these risk perceptions are not borne out by the epidemiology, which shows all members of the gay men and black African groups to be at a higher risk than the general population. It seems that this mistaken belief that the black Africans are at no higher risk level than the general population feeds into a misconception that they are being targeted – stigmatised – unnecessarily, which could undermine the effectiveness of awareness and prevention campaigns targeting this community (see below). This lack of awareness and differing levels of risk perception may need to be addressed by future interventions.

Both gay men and black African groups also believed that young people are most at risk due to their lack of knowledge of HIV. This suggests that these older groups think it is only younger people who need to change their behaviour to protect against HIV.

**Stigmatisation**

Whether they perceived themselves to be at higher risk or not, we were surprised to find that all the groups felt stigmatised by materials that only depicted people from their community. This included both images in the mainstream media and the information leaflets that were shown in the groups.

This sense of stigmatisation would benefit from further research, as it is likely to have a significant bearing on the success of future prevention interventions. Based solely on the discussions in the groups, it would seem that materials that target the black African or gay community, should not solely appear to do so (eg images of a range of ethnicities rather than just black faces) even if the messages have been tailored for these groups. In addition, marketing that has an authentic voice of the community, rather than a ‘hectoring’ authoritarian voice, may be better received and help to avoid this sense of stigmatisation.

**Media use**

Individuals from the focus groups mostly accessed mainstream media with limited use of both ‘gay media’ and media about countries of origin in Africa. This suggests that media placement of HIV messages for the target at risk groups should have an emphasis on the mainstream media but with additional targeted placement.

Although focus group participants said that they wanted HIV information to represent a range of communities, it is possible that this may be less relevant for information appearing in specialist gay or black African media. Information appearing in specialist media will be targeted by its very nature so tailored images and messages may be acceptable in these places, as long as they are part of an overall non-targeted campaign in the mainstream media. This area would benefit from further research.

**Grouping HIV with other STIs**

The female African groups also highlighted that they would prefer HIV information as part of general sexual health advice. They perceived sexual health in general as an issue rather than HIV specifically. This suggests that when HIV services for women are commissioned they should be integrated with other sexual health services or at least appear to be so for the public. Trusted sources

All groups highlighted that the NHS was a trusted source of sexual health information, and this included most local NHS organisations (although gay men stated that they often did not trust their GPs). In comparison, councils in particular were seen as inappropriate messengers. This poses a challenge to public health teams to communicate sexual health messaging, having been transferred to local authorities since April 2013. It would be useful to test this finding further, for example testing co-branded materials (ie NHS and local authority brands), which may in the longer term help to change attitudes to councils providing health messaging.

The suggestion from the groups is for national level NHS information but this could be commissioned on a London level and if local council branding is required due to funding sources these could be presented at a secondary, supporting level.

Participants were generally against receiving services or information about sexual health from local shops or community groups as they were seen to not have the relevant expertise or trustworthiness. However, there was awareness from black African groups that local community groups may have more understanding of their cultural context and the gay men were aware of groups like THT. A balance needs to be struck in commissioning between using trusted NHS sources and ensuring cultural context is properly understood.

Confidentiality and convenience

Finally, across the groups confidentiality was seen as more important than convenience with black African women in particular keen to maintain confidentiality by not going to local services. However, this wish for confidentiality needs to be balanced with ease of access so suggests that sexual health services could be promoted across London, rather than marketing by borough – in particular by lines of transport communications. 7 Appendices

7.1 Appendix 1 – Recruitment screening tools

7.1.1 Recruitment screening questionnaire – West African women

- Recruiting in Southwark, Lambeth, Lewisham and Greenwich – venue The George Inn, 77 Borough High Street, London, SE1 1NH
- Women only
- Recruitment screener: total to be recruited 10 – over recruit to 12
- £40 incentive

Contextual information

- We are carrying out market research to find out about where people get information on health and sexual and HIV health in particular. We’re offering a £40 ‘thank you’ for your time – if you agree to take part in a 1.5 hour workshop that’s taking place in The George Inn on Monday 9 September, Start 5:30pm – 7:00pm finish.
- The research is being run by Resonant Media on behalf of local councils in London (if pushed say: Directors of Public Health London”). Resonant Media is a totally independent agency – Any information you give will be handled totally confidentially.
- If you’re interested we’d like to ask a few questions which will take 2-3 minutes to complete to find out whether you are the type of person we need to talk to
- Some of the questions are personal in nature. If at any time you feel uncomfortable answering the questions, please just say so and we can stop at any time.

Do not read out – only offer if information requested:

- If you’d like more information on this research, please email londonhealth@resonantmedia.co.uk or call 020 7498 8055 and speak to Helena Ball

1. Could you tell me what ethnic group you would describe yourself?

| Black / Black African | Continue | |-----------------------|----------| | Other | Close |

2. Which country does your family come from originally? (suggest we use a card to show the different countries)

| Nigeria | Recruit 4 | | Country | Recruit (max) | |---------------------------------------------|---------------| | Ghana | (max 3) | | Gambia | (max 3) | | Sierra Leone | (max 3) | | Senegal / Guinea Bissau / Guinea / Liberia / Ivory Coast / Burkina Faso / Togo / Benin / Equatorial Guinea / Mali | (max 1) | | Cameroon | (max 1) | | Other | Close |

3. **Were you born in the UK or in the country you specified above?**

| Country | Recruit (max) | |---------------------------------------------|---------------| | UK | Q4 | | Family’s country of origin (ie not UK) | Q5 |

4. **If you were born in the UK, was your mother or father born in your family’s country of origin?**

| Country | Recruit (max) | |---------------------------------------------|---------------| | Yes | 4-5 | | No | Close |

5. **Do you work for, or do you volunteer, for any sexual health charity or community group?**

| Country | Recruit (max) | |---------------------------------------------|---------------| | Yes | Close | | No | Continue |

6. **Have you taken part in any market research, such as a discussion group, in the past 12 months**

| Country | Recruit (max) | |---------------------------------------------|---------------| | Yes | Close | | No | Continue |

7. **In which part of London do you live?**

| Country | Recruit (max) | |---------------------------------------------|---------------| | Southwark | 2-5 | | Lambeth | 1-3 | | Lewisham | 1-3 | | Greenwich | up to 3 | | Other London borough | up to 2 | | Not live in London | Close | 8. In the past six months have you been sexually active with your partner or another person?

| Yes | Continue | |-----|----------| | No | Close |

9. What was your age at your last birthday?

| Age Range | Recruit | |-----------|---------| | 25-29 | 2 | | 30-34 | 3 | | 35-39 | 3 | | 40-44 | 2 |

10. Are you in paid employment or a full time student?

| Yes | Recruit 8-9 | |-----|-------------| | No (unemployed) | Recruit 1-2 |

Other specifications:

- No more than 2 friends in any one group
- No family members in any groups

7.1.2 Recruitment screening questionnaire – gay men

- Recruiting in central London – venue in Soho Union Club, 50 Greek Street, London, W1D 4EQ
- Men only
- Recruitment screener: total to be recruited 10 – over recruit to 12
- £40 incentive

Contextual information

- We are carrying out market research to find out about where people get information on health and sexual and HIV health in particular. We’re offering a £40 ‘thank you’ for your time – if you agree to take part in a 1.5 hour workshop that’s taking place in Union Club on Tuesday 10 September, 6:30pm start – 8:00pm finish.
- The research is being run by Resonant Media on behalf of local councils in London (if pushed say: Directors of Public Health London”). Resonant Media is a totally independent agency – Any information you give will be handled totally confidentially. • If you’re interested we’d like to ask a few questions which will take 2-3 minutes to complete to find out whether you are the type of person we need to talk to • Some of the questions are personal in nature. If at any time you feel uncomfortable answering the questions, please just say so and we can stop at any time.

Do not read out – only offer if information requested: • If you’d like more information on this research, please email londonhealth@resonantmedia.co.uk or call 020 7498 8055 and speak to Helena Ball

11. How would you describe your sexual orientation?

| Option | Action | |-------------------------|--------------| | Gay | Continue Q3 | | Bisexual | Continue Q2 | | Straight/heterosexual | Close |

12. If you describe yourself as bisexual, do you meet male sexual partners on the ‘gay scene’ or through ‘gay networks’?

| Option | Action | |--------|--------| | Yes | Continue | | No | Close |

13. Do you live in London?

| Option | Action | |--------|--------| | Yes | Continue | | No | Close |

14. How long have you lived in London?

| Option | Action | |-------------------------|--------------| | One month or more | Continue | | Less than a month | Close |

15. Do you work for, or do you volunteer, at any gay men’s health charity or health group?

| Option | Action | |--------|--------| | Yes | Close | | No | Continue |

16. Have you taken part in any market research, such as a discussion group, in the past 12 months

| Option | Action | |--------|--------| | Yes | Close | | No | Continue | 17. In the past six months have you had sex with another man, who isn’t your regular long-term partner, if you have one?

| Yes | Continue | |-----------|----------| | No | Close |

18. Which London borough do you live in? [Read out options if necessary]

| Inner London | Recruit 6 | |--------------|-----------| | Outer London | Recruit 4 |

19. Do you use recreational drugs at parties, clubs or during sex (cocaine, ecstasy, crystal meth, mephedrone) in the past year?

| No | Recruit 3-4 | |----|-------------| | Yes| Recruit 6-7. |

20. Have you ever injected drugs recreationally such as crystal meth or mephedrone?

| Yes | Recruit 1-2 | |-----|-------------| | No | Continue |

21. What was your age at your last birthday?

| 21-29 | Recruit 2 | |-------|-----------| | 30-39 | Recruit 4 | | 40-45 | Recruit 4 | | Other ages | Close |

22. Could you tell me what ethnic group you belong to? | Ethnic Group | Recruit | |--------------------------------------------------|---------| | White British | 3-4 | | White other | 2-3 | | Black British / Black African or Caribbean / Asian| 2-3 | | Other ethnic group | up to 2 |

23. Are you in paid employment or a full time student?

| | | |----------|---------| | Yes | Recruit 8-9 | | No (unemployed) | Recruit 1-2 |

Other specifications:

- No more than 2 friends in any one group
- No family members in any groups

### 7.2 Appendix 2 – Discussion guide for gay men

| Timing | Discussion | |--------|------------| | 2 mins | **Introduction by facilitator**

- Introduce self and role and briefly explain purpose of the research
- Explain the research is confidential and anonymous
- Seek permission to record conversation
- Reassure that there are no right or wrong answers; we want honest views
- Some of the discussion may be quite personal.
- If there are questions they do not feel able to answer that is OK
- Respect others. We may not agree with what they say but everyone has their own views! | | 8 mins | **Getting to know the participants**\
  Each participant to introduce themselves
- Where do they live? How long have they lived in the area?
- A sentence about how they spend their day and what they like to do for recreation (capture where they work and socialise – at least at Borough level) | | 15 mins | **Talking about which channels or methods will reach them? Where they get information (general).**\
  Just thinking about a normal day during the week:
- What time do you get up?
- Do you read anything or listen to/watch the radio / TV before leaving home in the morning? If you read something, is that digital or print?
- If you are going out to work or somewhere else for the day, how do you travel?
- While you are travelling in the morning what do you normally do during the journey? (Buy newspaper? Take a free newspaper? Read magazines? Facebook? Other social networking?)
- During the day do you surf the net?
  - If you are at work, do you use any non-work sites on the computer, your tablet or your Smartphone? If so – which ones and what for?
- When you are on your way back home at the end of the day, what do you do? Read, listening to music, use mobile apps etc
- Once you get home do you call / text / email friends etc or interact with them online / via social networking (NB landline or mobile?)
- What about at the weekend? Do you do anything very different?
- Which newspapers or magazines or radio or TV stations do you read / listen to most often? Spontaneous and prompted | Offer a list that includes mainstream / national / gay specific etc. And including free and paid for

Probe consumption of free pan-London media such as Metro, Standard, Shortlist, TimeOut

- Do you have any subscriptions to newspapers / magazines – paper or online?
- Do you ever listen to / read any of the following? If so, what do you find most interesting / least interesting?

Show list of gay media and note awareness and levels of interest

| 15 mins | Knowledge and perceived risk and general ‘relevance’ of HIV to group (Based on the health belief model explore perceived seriousness of and susceptibility to the issue) | |---------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------| | | o How important is your health to you? | | | o What would you say is your biggest priority around your health? | | | o Do you have any particular worries at the moment? | | | o What do you understand by the term “HIV”? Probe | | | o What is it? | | | o How serious is HIV? What’s the impact of HIV on people’s health / lives? | | | o How does someone get it? | | | o Can you tell if someone is HIV positive? | | | o Who do you think is at greatest risk of getting HIV (probe people or groups)? | | | o Is the risk limited to these people or are there others? | | | o What puts them at greatest risk? | | | o Does someone have to be part of one of these groups to get HIV? | | | o Do you know anyone who has HIV? | | | o Are you worried about HIV personally? | | | o Do you worry about your friends and family and HIV? Do you think you or they may be at risk of being infected | | | o Would you do anything particular to reduce your risk of getting HIV? | | | Probe | | | o What would you do? | | | o How would you protect yourself? |

| 20 mins | Specifically about Sexual health and HIV information | |---------|-----------------------------------------------------| | | If you want specific information relating to sexual health and HIV where would you go for information if you wanted to find out about: | | | Safe sex |

www.resonantmedia.co.uk | 10 mins | **How do they want to be reached / communicated to about HIV – in particular prevention messages?** | |---------|--------------------------------------------------------------------------------------------------| | | **Probe:** | | | • Would you want to receive messages about HIV – and in particular how to prevent getting it? | | | • What would be the best way to give you, and other people at risk of getting HIV information about HIV? | | | **Probe:** | | | o *In person - one-to-one or groups, locally or happy to travel?* | | | o *Online – websites* | | | o *Email (personal or work)* | | | o *Text messages* | | | o *Phone calls (landline or mobile)* | | | o *Features or adverts on TV/radio/in print media* | | | o *Small printed media like leaflets or letters, at home via post etc or in doctor’s surgery, at the gym, in a bar, in a hairdressers/barbers, in a shop like Boots or ASDA.* | • What are some of the other issues? Probe o *Is privacy an issue?* o *Would they prefer individual focused methods (like text messages or letters) or more general ones which they can take or leave – like billboards or radio/press adverts or features)?* o *Would you prefer to have information ‘pushed out’ to you / unsolicited (passive) or to have the information easy to find when you are actively looking for it (active)?* o *If they mention word of mouth push beyond this – where does the information come from originally?* o *Leaflets and ask further – where and when would these be appropriate? What would they do with them?* o *Would it be better use Smartphone rather than desktop to access online information as more personal/private).*

• What is the best / easiest way of getting condoms and lube? *(Order online, buy from shops like Boots/pharmacy, from doctor/clinic/hospital, from bars (behind bar/in toilet), from gyms, hairdressers etc)*

| 20 mins | Trust and credibility, recognitions and awareness | |---------|--------------------------------------------------| | • Are there any sexual health or HIV information campaigns that you remember? Probe | | o *Where seen* | | o *What can they remember of it (i.e. messages, organisation that ran it) and what they thought about it? (Trust, useful? Act on it?)* |

• If you were to be given information about HIV who are the most appropriate organisations to give you this information? Who would you trust to give you the right information? *Probe* o *What would make you to trust one organisation more than another?* o *Does the type of organisation depend on the subject? E.g. safer sex/types of sexual practices/what to do during sex to reduce your risk of infecting or catching HIV; privacy etc* o *How important is it that the organisation understands your religious and cultural beliefs?* o *Does how local the organisation is affect your level of trust? E.g. local council or clinic vs London-wide or national organisation*

• I’m going to show you some names of organisations. Thinking about who you think you would trust and want to receive information from about HIV, please indicate which organisations: (Handout) o *you would want to talk to you about HIV*

- you are indifferent to
- you would not want to give you information
- you have not heard of and don’t know what they do.

**Probe** - reasons for the answers and what people think of the different brands /organisations?

(List to include: GPs, Pharmacists, Hospitals, Sexual health clinics ‘NHS’ vs. local NHS organisations Councils; Central govt, including Dept of Health; Gov.UK (formerly DirectGov) NHS Direct; NHS England / Public Health England / HIV Prevention England Terence Higgins Trust Community and charity groups (including religious) Shops including Boots, Lloyds, ASDA, Tesco Some will not have logos but explore church, hairdressers, gyms etc

If there is time refer to previous materials.

- What do you think about the materials? Do you recognise them? How do they make you feel? Are they appropriate? What would you do with them – if given out in public / in a bar / posted to you?

| 2 mins | **Round up, thanks and close** | |--------|-------------------------------| | | Final thoughts | | | Next steps and developing a programme | | | Thanks |

### 7.3 Appendix 3 – Discussion guide for black African groups

| Timing | Discussion | |--------|------------| | 2 mins | **Introduction by facilitator**

- Introduce self and role and briefly explain purpose of the research
- Explain the research is confidential and anonymous
- Seek permission to record conversation
- Reassure that there are no right or wrong answers; we want honest views
- Some of the discussion may be quite personal.
- If there are questions they do not feel able to answer that is OK
- Respect others. We may not agree with what they say but everyone has their own views! | | 8 mins | **Getting to know the participants**\
  Each participant to introduce themselves
- Where do they live? How long have they lived in the area?
- A sentence about how they spend their day and what they like to do for recreation (capture where they work and socialise – at least at Borough level) | | 15 mins | **Talking about which channels or methods will reach them? Where they get information (general).**\
  Just thinking about a normal day during the week:
- What time do you get up?
- Do you read anything or listen to/watch the radio / TV before leaving home in the morning? If you read something, is that digital or print?
- If you are going out to work or somewhere else for the day, how do you travel?
- While you are travelling in the morning what do you normally do during the journey? (Buy newspaper? Take a free newspaper? Read magazines? Facebook? Other social networking?)
- During the day do you surf the net?\
  1.1 If you are at work, do you use any non-work sites on the computer, your tablet or your Smartphone? If so – which ones and what for?
- When you are on your way back home at the end of the day, what do you do? Read, listening to music, use mobile apps etc
- Once you get home do you call / text / email friends etc or interact with them online / via social networking (NB landline or mobile?)
- What about at the weekend? Do you do anything very different? | | 15 mins | Knowledge and perceived risk and general ‘relevance’ of HIV to group (Based on the health belief model explore perceived seriousness of and susceptibility to the issue) | |---------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------| | | • How important is your health to you? | | | • What would you say is your biggest priority around your health? | | | • Do you have any particular worries at the moment? | | | • What do you understand by the term “HIV”? Probe | | | • What is it? | | | • How serious is HIV? What’s the impact of HIV on people’s health / lives? | | | • How does someone get it? | | | • Can you tell if someone is HIV positive? | | | • Who do you think is at greatest risk of getting HIV (probe people or groups)? | | | • Is the risk limited to these people or are there others? | | | • What puts them at greatest risk? | | | • Does someone have to be part of one of these groups to get HIV? | | | • Do you know anyone who has HIV? | | | • Are you worried about HIV personally? | | | • Do you worry about your friends and family and HIV? Do you think you or they may be at risk of being infected | | | • Would you do anything particular to reduce your risk of getting HIV? Probe | | | • What would you do? | | | • How would you protect yourself? |

| 20 mins | Specifically about Sexual health and HIV information | |---------|-----------------------------------------------------| | | If you want specific information relating to sexual health and HIV where would you go for information if you wanted to find out about: | | | • Safe sex |

• Which newspapers or magazines or websites or radio or TV stations do you read / listen to most often? Spontaneous and prompted

*Offer a list that includes mainstream / national / African specific etc. and including free and paid for*

*Probe consumption of free pan-London media such as Metro, Standard, Shortlist, TimeOut*

• Does language affect which newspapers or TV/radio you read or listen to? Which language would you prefer to read/listen to?

• Do you ever listen to / read any of the following? If so, what do you find most interesting / least interesting?

*Show list of African media and note awareness and levels of interest* | 10 mins | **How do they want to be reached / communicated to about HIV – in particular prevention messages?** | |---------|--------------------------------------------------------------------------------------------------| | | • Would you want to receive messages about HIV – and in particular how to prevent getting it? | | | • What would be the best way to give you, and other people at risk of getting HIV information about HIV? | | | **Probe:** | | | o *In person - one-to-one or groups, locally or happy to travel?* | | | o *Online – websites* | | | o *Email (personal or work)* | | | o *Text messages* | | | o *Phone calls (landline or mobile)* | | | o *Features or adverts on TV/radio/in print media* | | | o *Small printed media like leaflets or letters, at home via post etc or in doctor’s surgery, at the gym, in a bar, in a hairdressers/barbers, in a nail bar, in a shop like Boots or ASDA.* | • What are some of the other issues? Probe o *Is privacy an issue?* o *Would they prefer individual focused methods (like text messages or letters) or more general ones which they can take or leave – like billboards or radio/press adverts or features)?* o *Would you prefer to have information ‘pushed out’ to you / unsolicited (passive) or to have the information easy to find when you are actively looking for it (active)?* o *If they mention word of mouth push beyond this – where does the information come from originally?* o *Leaflets and ask further – where and when would these be appropriate? What would they do with them?* o *Would it be better use smartphone rather than desktop to access online information as more personal/private).*

• What is the best / easiest way of getting condoms? *(Order online, buy from shops like Boots/pharmacy, from doctor/clinic/hospital, from bars (behind bar/in toilet), from gyms, hairdressers etc)*

| 20 mins | Trust and credibility, recognitions and awareness | |---------|--------------------------------------------------| | • Are there any sexual health or HIV information campaigns that you remember? Probe | | o *Where seen* | | o *What can they remember of it (i.e. messages, organisation that ran it) and what they thought about it? (Trust, useful? Act on it?)* | | • If you were to be given information about HIV who are the most appropriate organisations to give you this information? Who would you trust to give you the right information? | | *Probe* | | o *What would make you to trust one organisation more than another?* | | o *Does the type of organisation depend on the subject? E.g. safer sex/types of sexual practices/what to do during sex to reduce your risk of infecting or catching HIV; privacy etc* | | o *How important is it that the organisation understands your religious and cultural beliefs?* | | o *Does how local the organisation is affect your level of trust? E.g. local council or clinic vs London-wide or national organisation* | | • I’m going to show you some names of organisations. Thinking about who you think you would trust and want to receive information from about HIV, please indicate which organisations: (Handout) | | o *you would want to talk to you about HIV* |

- you are indifferent to
- you would not want to give you information
- you have not heard of and don’t know what they do.

**Probe** - reasons for the answers and what people think of the different brands /organisations?

(List to include: GPs, Pharmacists, Hospitals, Sexual health clinics ‘NHS’ vs local NHS organisations Councils; Central govt, including Dept of Health; Gov.UK (formerly DirectGov) NHS Direct; NHS England / Public Health England / HIV Prevention England Terence Higgins Trust Community and charity groups (including religious) Shops including Boots, Lloyds, ASDA, Tesco Some will not have logos but explore church, hairdressers, nail bars, gyms etc

______________________________________________________________________

If there is time refer to previous materials.

- What do you think about the materials? Do you recognise them? How do they make you feel? Are they appropriate? What would you do with them – if given out in public / in a bar / posted to you?

| 2 mins | **Round up, thanks and close** | |--------|-------------------------------| | | Final thoughts | | | Next steps and developing a programme | | | Thanks | 7.4 Appendix 3 – Logo images used in focus groups

- **NHS**

  - The NHS

- **Central and NorthWest London**

  - NHS Central and NorthWest London

- **Guy’s and St Thomas’**

  - NHS Foundation Trust
  - Guy’s and St Thomas’ Hospitals

- **Burrell Street Sexual Health Centre**

- **Ealing Hospital**

  - NHS Trust
  - Ealing Hospital

- **SHO-me**

  - Sexual Health Online for North East London

- **NHS**

  - The NHS

- **Central and NorthWest London**

  - NHS Central and NorthWest London

- **Chelsea and Westminster Hospital**

  - NHS Foundation Trust
  - Chelsea and Westminster Hospital

- **56 Dean Street**

- **Burrell Street Sexual Health Centre**

- **NHS Westminster**

  - NHS Westminster

- **SHO-me**

  - Sexual Health Online for North East London